Acute Appendicitis Diagnosis and Management

Clinical Presentation

The progression from periumbilical pain to right lower quadrant (RLQ) localization is the hallmark presentation of acute appendicitis, occurring as visceral pain from appendiceal distension transitions to parietal peritoneal irritation, according to the American College of Radiology 3, 4
At 10 years old, this patient is in the peak age range for appendicitis, which is most common during adolescence, as reported by the American College of Radiology 3

Ultrasound should be performed immediately as the initial imaging modality due to zero radiation exposure and good diagnostic accuracy for appendicitis and complications like perforation or abscess, as recommended by the American College of Radiology 3, 1
If ultrasound is equivocal or non-diagnostic, proceed directly to CT abdomen/pelvis with IV contrast or MRI, which provide 90-94% sensitivity and 94-98% specificity for appendicitis and perforation, according to the American College of Radiology 5, 1

Treatment of perforated appendicitis with abscess typically requires percutaneous drainage, broad-spectrum antibiotics, and either immediate or interval appendectomy, depending on clinical stability, as recommended by the American College of Radiology and the American College of Surgeons 3, 1

Never discharge a patient home based on pain improvement alone after severe RLQ pain, as this may represent the dangerous "calm before the storm" of perforation complications, as warned by the American College of Surgeons and the American College of Radiology 2
Clinical examination alone is notoriously unreliable for appendicitis diagnosis, with negative appendectomy rates as high as 25% when imaging is not used, highlighting the importance of imaging in diagnosis, as reported by the American College of Surgeons and the American College of Radiology 2